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example, a child might have been sent up by the Invalid Children's Aid Association or the school medical officer
to the supervisory centre because he was ailing or complaining of pains in the limbs ; his condition on visiting the
centre might have been doubtfully rheumatic, and would not have warranted notification were it not for the
fact that the history revealed that the child had had chorea or acute rheumatism at some previous date before
compulsory notification ; such cases were frequently notified. Again, general practitioners and school medical
officers notified cases with such signs as mitral stenosis, although the children may have had no present symptoms
of the infection ; they were notified because the doctors knew from the history and the signs found that the
children had had juvenile rheumatism with cardiac involvement, and that they had not been previously notified
because the disease occurred before compulsory notification. As the period of notification lengthens, this type
of notification will not occur as frequently.
Juvenile rheumatism does not resemble most other notifiable diseases in which one attack usually confers an
immunity and second attacks are therefore uncommon. In these other diseases the notification statistics are
straightforward ; in rheumatism, however, not only does one attack fail to confer an immunity, but it definitely
increases the danger of the occurrence of subsequent attacks. Until notification has been in force for a few years,
therefore, the number of notifications does not give any real indication of the number of cases occurring for the
first time in the borough during any particular year. For this reason only, therefore, it would seem to be a pity
to cease to notify just when the statistical value is becoming apparent.
There are other reasons, however, in favour of the continuance of compulsory notification :—
(1) The etiological investigations up to the present have been mainly negative in character. Investigations
into environmental factors have revealed that no evidence can be produced to show that there is any
connection between the onset of juvenile rheumatism and damp areas, rat infested areas, and various soils.
The only definite positive finding is that rheumatism increases directly with poverty and the overcowding
and malnutrition consequent on this state. It appears, therefore, that further etiological investigations
will have to be made. For this purpose the notification lists will be of value.
(2) When a child is first seen by the general practitioner, or at a supervisory clinic or ordinary out¬patient
department of a hospital, the history given is extremely vague. It may not be the mother who
brings up the child, or if it is, her recollection of the child's previous illnesses is often very inadequate. She
may forget that the child has had any suggestive symptoms, or alternatively she may say that a nervous
fidgety child has had St. Vitus Dance, or a debilitated flat-footed child has had rheumatism. If, however,
it is found that the child has, at some time, been notified under the Royal Borough of Kensington scheme,
it is definitely established that the child has had one of the notifiable rheumatic conditions.
(3) It was pointed out in the second annual report that though notification would not be likely to supply
a large proportion of the cases sent to the supervisory centre, it is bound to keep under supervision certain
cases which would otherwise be neglected and so run unnecessary risks of cardiac complications. It is true
that in order to be notified the cases must have come under medical care on at least one occasion, but
unfortunately private medical practice in this country has but little opportunity to concern itself with persons
not actually ill. There is enormous scope for preventive work and for the supervision of the healthy in
private practice, but as yet medical evolution has not accomplished any considerable development along
these lines, and the incomes of the class of family amongst which juvenile rheumatism is rife are such that,
as a rule, the child has not only to be ailing but quite definitely ill before the fee can be found for the private
practitioner.
Social Services.
In the annual report of the Kensington rheumatism supervisory centre for the year 1931-32, details were
given of the work carried out by the honorary secretary of the rheumatism supervisory scheme and her
assistants, and it is not intended in this report to repeat them, but to illustrate briefly instances in which the
services of social workers are of extreme value in connection with the work of the centre.
On the first attendance of a child at the centre, many problems may arise. For example, if the home
conditions, etc., have not been investigated and the physician in charge is therefore not familiar with them,
much valuable time is wasted. Before a child is summoned to attend the centre, it is the practice for a social
worker to visit the home with a view to obtaining details of the family circumstances, and explaining to the mother
the importance of the disease from which the child is suffering, and the dangers that may result if proper precautions
are not taken. Further, if the child is very ill, the social worker will probably warn the parents that it may
be necessary to send the child to hospital for in-patient treatment. Considerable help in the choice of treatment
is very often given to the physician in charge by the social worker's knowledge of the home conditions and
financial circumstances of the family. For example, a child suffering from a choreic or cardiac condition can
often safely be allowed to receive home treatment when the parents are of good social class and intelligent, whereas
if the child comes from an overcrowded tenement, where he cannot get proper rest or the necessary attention
from his mother, hospital treatment is essential.
Lack of proper feeding, and insufficient sleep play an important part in choreic cases. Many poor, ignorant
mothers have been gradually educated by the tactful social worker in the importance of proper nourishment and
adequate rest.
Tonsillectomy and remedial exercises are two methods of treatment ordered by the physician in charge,
which are often disliked and objected to by parents; tonsillectomy because of fear of operations, and remedial
exercises because of the time which has to be given by the parents to supervision of the child during the course
of the exercises. The social worker is often able to impress on parents the necessity for these forms of treatment,
and to secure either their sanction to the operation or their enthusiasm in seeing that the child has his exercises
regularly.
Private doctors frequently send patients to the centre for diagnosis and advice upon treatment, but in many
cases the mother is not quite certain whether the physician in charge is to treat the child or only to act as a
consultant. Here again the social worker will investigate and consult the private doctor concerned, with a view
to ascertaining his exact wishes, and valuable co-operation between the centre and the private practitioners in
the borough is thus ensured.
In the early days of the centre, close co-operation with parents was very difficult, and it was only by the
continued efforts of the voluntary workers, involving much time and patience, that this was effected. In some
cases the difficulty still arises. Social work in connection with the centre is thus essential to complete successfully
the work of the physician in charge.
The social workers on the staff of the Kensington Rheumatism Supervisory centre at the present time are
as follows :—one honorary secretary, Mrs. Jacobson, one paid secretary, Miss Butler, and three voluntary home
visitors, Miss Dudley Baxter, Miss Reitlinger. and Miss Greer. Their work is invaluable; it is due to their
patience and perseverance that children attend so regularly, and that few cases lapse through need of visiting.